Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Thursday, July 26, 2007

Are You Experienced?

The news of the week includes reference to an article about a study of surgeons doing prostate cancer surgery. Experience counts, it reports; surgeons doing fewer than ten prostatectomies for cancer have significantly poorer results than those doing more than two-hundred fifty (now there's a hell of a range!) The researchers also conclude: if you have cancer surgery, you ought to go to a teaching hospital. They're half right.

In the early years of my practice it sometimes happened that I'd lose a patient to the big city surgeons. Typically it was for breast cancer: I'd see her, do the appropriate workup including a biopsy of some sort, have a lengthy discussion of the surgical options. Back then, given a less-than-full schedule, I even went to people's homes to break the news, sometimes. Very appreciative: "You've done a really great job, doctor. I like you a lot. But my friend had a surgeon in Seattle, and, well, he's been around a long time and, well, you know..." It took a few years before it stopped happening -- probably at least as coincident with my premature graying as with anything meaningful. But in time, for whatever reasons, the outflow stopped; in fact, there was the not entirely rare inflow from those parts...

In describing my mentors and their influence on me, I've said I thought I didn't fully get what they were trying to impart until I'd been out from under them for a couple of years. It's true. But in the context of the article in question, I'm trying to consider in what ways it's the case. Smoother; faster; more confident. An evolving sense of how I saw myself and what I wanted to be. But safer? Getting better outcomes for my patients? I'm inclined, of course, to say no; but maybe data would show otherwise. It's not the first time an article has appeared tying outcome to experience. It certainly makes intuitive sense. And yet it's not the whole story. If I could figure it out ahead of time, I'd rather be operated on by a less-experienced surgeon who does things right than one with hundreds of cases under the belt, done less well.

When I've given readings of my book, a question I'm regularly asked is how to find a good surgeon. It's a toughie, for the non medically-connected person. I begin with the idea of trusting your primary doc; if you have one you like and believe in, you ought to be able to assume she or he wouldn't steer you wrong. Other than the occasional political issue, and the fact that most primary docs don't really understand what goes on in an operating room, I think it's a good bet. Whatever else is true, they do see the patients again after they've sent them off; flesh-and-blood feedback. And, of course, credentials mean something. Training at an excellent program increases the likelihood that a surgeon knows his or her way around a body. Doesn't guarantee. Nor is the opposite true: one of the best surgeons I know trained at a pretty unremarkable place.

Not every operation I learned ended up in my armamentarium in practice. And here's the tricky part: I didn't reject certain cases just because I didn't do them often. Some operations, while complex and challenging, involve nothing but a combination of techniques I used all the time: Whipple procedure; esophagogastrectomy. Uncommon as they might be in terms of numbers, my ability to do them and do them well was not in question. Not in my mind, at least; nor in the outcomes. Other operations involved either techniques I didn't employ regularly, or had the potential for post-op complications with which I didn't deal often enough to feel like I had the breadth of judgment to bring to bear. So I didn't do them: major liver resections; colectomy with ileo-anal pouch creation. (In regards to the latter, I helped a recently minted surgeon do one and showed her a few tricks that shaved a couple of hours off her operative time and smoothed the patient's recovery.) I could do any of those; but I didn't.

What are we to do with this experience/outcome data? If we only go to experienced surgeons, at some point there won't be any, right? How do you get patients if you need to have had patients to get them? Anyone want to sign up to be fodder?

New procedures have, without question, a learning curve. It takes time to get the hang of laparoscopy, for example. One would like to think that, after several years of long days and nights and rigorous supervision, any trainee would come out the other end knowing how to operate. If you know principles of dissection, of exposure, how to handle various tissues, you ought to be able to translate that to most any operation in a way that keeps the patient safe and provides the expected outcome. Somewhere in my mind, in ways I can't entirely sort out -- yet -- it seems to be that there's more going on here than experience with a particular operation.

If there's a solution to the patients' dilemma -- knowing where to go for what procedure -- it ought to involve some sort of mentoring program for surgeons. I may not need to have done two hundred repetitions of an operation if I've received the benefit of training by someone who has. That is, of course, what residency training is all about. But there's more to it than that. My surgical life is entirely involved with a single laparoscopic procedure nowadays. Three surgeons, three anesthesiologists doing one procedure, over and over. From the point of view of smooth operation, in all senses of the word, it's a soaring pleasure. Likewise outcomes. And when other surgeons are planning to start doing that operation, they must be mentored for several cases before getting privileges to do it on their own. These guys are among those that do the mentoring. It might be ideal if for each operation there were such super-specialty centers. But is that practical? Wouldn't people prefer not to have to scatter their body parts across the country?

With the advent of the eighty-hour work week (which, according to many of my pals in academic surgery, is diluting the experience of trainees), such a thing becomes even more critical. If the American College of Surgeons had the resources, it would be arranged that every new surgeon, on completion of training, would be taken under the wing of one who'd been around the block a few times. Such a program would identify those that need a little more polish before being loosed on the world, would impart the knowledge that only comes (apropos that comment about the need to go to training hospitals for certain precedures -- the best surgeons I know, by far, are those in private practice) from being in private practice; and most importantly -- assuming such a thing were possible (probably not) and done in a meaningful way (conceivable) -- would give patients the confidence that they'd be getting a good product when they expose themselves to the surgeon's knife.

18 comments:

Forgive me for being a little slow on the uptake here so would a surgeon who has a private practice but also works in a teaching hospital be the optimum choice? Then of course there are exceptions for various reasons.

I think I am going to start a Dr Schwab- Surgeonsblog file. I want to go back over your posts and pull the ones that may be useful in the future should I or anyone else I know ever need surgery. Lots of good info in this blog. So glad you are here! :)

I think you get a wider range of good to bad in private practice. There are some terrible surgeons making money in the private world. As a PCP, I have some of each that I use. For less-specialized surgeries, I use the general surgeons that I would (and have) use myself. We have an ENT at the local teaching hospital who is renown for his minimally invasive thyroid and parathyroid surgeries. I send all of those procedures to him. So I think it really depends on the procedure.

Rob: I think your point about a wider range in private practice is well-taken. On the other hand, some of the best teachers -- in terms of judgment, experience, wisdom -- I had in training were far from the best operators. And your selection of surgeons confirms my comment about people putting trust in their primary docs when it comes to referral time.

When I lived in a small town, word of mouth was the method of choosing a surgeon or doctor. I don't remember who said the following, but it has always stuck with me....An older doctor has more experience, but a young doctor who has recently begun practice has learned the latest and greatest. Although any respectable older doc keeps up on the latest and greatest, I suppose there is some truth to both. I have seen young surgeons with remarkable technique and good outcomes, and young surgeons who are tentative and unsure of themselves. It's hard now, on the inside looking out, to know how to help someone choose.Personally a lot does depend on the procedure, but I tend to lean towards experience over youth. I would love to assist in a teaching hospital, but I'm not so sure I would want to be operated on at one.

As a young surgeon just starting out in practice, I too have lost a couple cases to the big tertiary referral centers. All of them had to do with breast cancer. It's frustrating and a little humbling. Breast cancer requires a lot of office time spent discussing pathophysiology of the disease, diagnostic options, and the varying treatment protocols. You build a relationship. You sense the woman trusts and understands what you're saying. And then you get a message from your office worker saying Mrs. so and so decided to have her surgery done downtown. All that work....

And breast surgery, technically speaking, is not exactly like doing a Whipple. It's pretty straightforward, basic surgery. Not that any idiot could do it, but I don't think surgeons are doing breast fellowships to become more adept at the intricacies of lumpectomy. It's a cse you pretty much master by third year of residency.

The other thing about the large tertiary referral centers you have to consider is that these are "teaching" centers. Teaching means "resident does the case" in many of the basic general surgical cases. If you're flying to Johns Hopkins to get your gallbladder taken out, you're probably fooling yourself if you think John Cameron is the guy actually doing the case.

Enjoyed the post as well. As a 3rd year resident at an academic medical center, I agree with most of has been said. I agree with Dr. Schwab - some of the slickest surgeons out there are in private practice. Why? They operate much more and can focus on efficiency and technique rather than showing the resident where to Bovie. Regarding the breast patient who chooses to go "downtown" - unknowingly, she just signed up to let me (actually, usually an intern) do her lumpectomy and sentinel node. Having said that, the resident rarely "does" the case; we are always under close scrutiny and most attendings will take the case over if they see too much fumbling). One of the better reasons to go "downtown" is probably the multidisciplinary effort at a larger center - oncologist, surgeons, radiation oncology - although community centers have these teams as well.

What if you are a patient referred by your surgeon to go to a teaching hospital because you were a high risk case and felt you'd be better off in a facility with around the clock care (Doctors on staff 24/7) and also be on a wing that specializes in your particular post-op care?

seaspray: it depends on the surgeon, and, to some extent on the relationships. If you're there on direct referral to a surgeon and you are his/her "private" patient, it might be that the surgeon would do every bit of the operation him/herself. But not necessarily. In teaching institutions, there's an understanding that all or part of an operation might be done by residents, under the direct supervision of the attendings. There's no hard and fast rule: it's something a patient can feel free to ask their surgeon.

Tough questions about who does the case. As a plastics resident, I often hear patients ask the faculty, "You'll be doing the surgery, right?" My faculty are very dedicated to resident education. They always respond, "No, the resident does a significant portion of the operation. I supervise him (or her) the entire time and may do parts that they aren't ready to do. But if I don't let them do operations now, there won't be anyone around who knows how to do them ten years from now when I'm retired."

Patients usually understand after that, but I'm sure some do schedule with the private guys instead.

We've seen enough of these studies at this point to I think generalize: those who do more of X procedure do a better job than those who do only a few.

For the reasons discussed, there's only so much we can learn from this, and we have to suspect there are some other very important lessons to be learned. Surely, volume isn't the ONLY criterion that is important. What we need now is a more in-depth analysis of approach, training and techniques that go along with better outcomes, some of which may relate to volume, some of which may not. You have to wonder if some of the volume difference is related to surgeons developing a restricted practice, limiting themselves to a shorter list of procedures which they are comfortable doing, then doing a lot of them.

After all, if we cannot understand any better than more is better, how are we to advance the care of patients?

I have the sense that there are some who will never be notably good surgeons regardless of how many times they do a given procedure -- a sad but true fact, I think.

It's also a strange range, this particular study: 10 vs 250. What about eveyone in between? Another solution I failed to mention is the progress being made in "virtual surgery," whereby trainees can get more and more realistic technical experience without drawing blood.

Wow... this touches on so many difficult to discuss (and blog about) topics. As an academic surgeon, my patients want to know who will be doing the procedure. Our newest consent forms have check boxes detailing various tasks that the residents might be doing: incision, resection, tissue rearrangement, implants, closing, etc.

I am struggling to know how to address these issues with patients and families. It is not straightforward.

I think one has to have a serious "meta-understanding" of something to say one has truly mastered it on one's own. Until then, it's apprenticeship, picking up more bits of knowledge along the way. That may not translate 100% with pure surgical skill (time, etc.), but I'd consider it a prerequisite (in a perfect world, from my point of view, of course :P) for true "solo flying" in private practice. Just knowing how to do a thing and doing it over and over the same way just shouldn't be "good enough," at least not for me.

Patients get overwhelmed by commercial hype. In prostate cancer surgery, they encounter distracting hype in the form of device ads. Much more important to ask who's my surgeon than to ask who's my gizmo? This point is reviewed in a recent podcast on laparoscopic and robotic prostate surgery produced by the Prostate Net.

A 'balanced perspective' seems to be a well worn phrase when measuring some results, particularly those cases that generally don't have a great mortality rate. Poor patient selection can undo the best of them. There are many talented operators, but with a poor prognosis, how can you measure up?

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Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.